The use of public reporting (PR) of hospital performance and hospital pay-for-performance (P4P) incentives that reward hospitals for delivering higher quality of care is increasing in California and nationally. The assumptions underlying quality-based purchasing (QBP) strategies are that disclosure of comparative quality will allow consumers and purchasers to choose the highest quality providers and that selective purchasing or other financial incentives will create market pressure to promote quality. Currently P4P and PR are used primarily by commercial insurers and the Medicare program. It is unclear how PR and P4P policies will affect the quality of care at safety net hospitals (SNHs) that treat few privately insured and Medicare patients, have patient populations with little choice in providers, or-like many rural hospitals-face little market pressure. There is little prior research addressing the potential impact of PR and P4P policies on SNH. This study aims to elicit California SNH executives' concerns regarding PR and P4P and their suggestions for optimizing the benefits and minimizing the harm caused by PR and P4P, and then assesses the feasibility and acceptability of those suggestions to government regulators, purchasers, and non-SNH executives. The study will have 2 stages. We will first perform a document and literature review to expand our conceptual model of how current policies and market factors enhance or limit the impact of incentives on SNHs. This will include archival analysis of California Medicaid mandates and regulations and interviews of key government informants about current Medicaid and Medicare policies. After expanding our conceptual model, we will test it using qualitative semi-structured in-depth interviews of a purposeful sample of California SNH executives and government regulators, government purchasers, and executives at non-SNH hospitals. In the interview, we will ask SNH executives about current participation in PR and P4P and the value of the incentives existing PR and P4P initiatives offer to SNHs, about the market and financial factors that influence SNH decisions to participate, and about suggestions for future approaches to PR and P4P that might be more attractive and useful to SNHs. We will then present their policy proposals to government regulators and purchasers, health plan executives, and executives at non-SNH hospitals to assess for feasibility and acceptability of their suggestions. All interviews will be analyzed in an iterative fashion using NVivo software for qualitative data analysis with the aim of developing a conceptual model of the determinants of SNH responses to PR and P4P incentive. [unreadable] [unreadable] [unreadable]